FORM-6 (See Rules 1(1) and (26) of the Registration of Electors Rules, 1960) ELECTION COMMISSION OF INDIA Application Form for New Voters Acknowedgement Noss1825606N0408241200016 (Tobe led by ofce) To, ‘The Electoral Registration Officer, No, & Name of assembly Constituency No zi Name: Wai (OF No. & Name of Parliamentary Consttuency@ No Name: (@Ony for Urion Tetons not having Lepsatve Assembly) | submit aplication forinclsion of my name inthe electoral ol forthe cbove constituency (1(@) Name (In ofetal Language of State) First Name followed by Middle Neme FRR wera Surae (if any) BTR (1b) Name In Engish in BLOCK LETTERS) First Name followed by Middle Nome VISHAL EKANNATH Suman (if any) LANADAGE Disclaimer: fname not filed in English i wil be transiterated by software *(2\) Name and Surname (in ffi anquageof State) of anyone ofthe relatives: Father or Mother [7] oF Husband or Wile or Legal Guardian in case of orphan/Tird Gender (2\} Name and sumeme (in English in BLOCK LETTERS ofthe relate mertioned above GITANJALI LANADAGE atort ast (9) Mobile No.of ef f availble), otelel:olsTelv12)« Of relative metioned at er No.2 (4) Email bof Self (avaiable) or Of relative mentioned at ter No.2 (5) Aadhaar Det a7]slefel+folelslalel7 (©) ener wuz [7 FEMALE “THRO GENDER (2¥e)oateo sh (drmmy799) offs] [1 fz] 4 [2 fools (b) Se atesed cory of document supprtng age prot attached (anyone othe folowing) {) Document for roa of Date a ity (ny oe ofthese) 1 |. ith cerifcate issued by Competent ca ay Municipal thy Regstar of Births & Deaths 2) Aadhaar cart sl] PaNcad 4] ving License sl) ceriteales of Cas or Class Mlissued by CBSE/CSE/ State EdvcationBordiitcotsinDalefith 6 | Indian Passport (i) Any ter Document for Proof of Date of Birth fn documents availabe) PI. Specify)1B (@) Present Ordinary Residence Ful Address) House/Suling/Apartment No. KISANVEER CHOWK Frere ‘StreetiArea/Locaiy, MAINROAD Fas ‘TehsivToluga Maral KHANDALA 2STER ‘Tomvviage KHANDALA @STER Post ofice KHANDALA ST ‘StateuT- Maharastra Distlet Satara Pin Code 412002 (b) Sefattested copy of eds proof ether nthe name of appliant or any one of parets/spouse/adult ci f eed eroled as elector athe same adress (tach enyone of them) (@ Document er proof of residence 1{___| Wetelectristoas connection Bile thatadres(atieast1 yar) 2] Aathaarcars {| Curent passbookot NetioralzedSchedued BarkiPost Offce 4 incon Passpert 5] | Revenue eparmeats Land Oaning record nsudngKsan Bah 6l | regsteredRent Lease Deedineseof tenet) 1 Aegistered Sale Deedncase of own hose) (i) Any Oter Document fer Poot of eidence: (no documents avaabe (Fl. Spec). (@jcategory of sissy if any (Options) Locomative Visual Dest & um anyother (Give description Percentage of disability fs Certiost attache (Tick the sppropiste tox) Yee No (10yThe deta of my family member already included inthe electoral ol at current adress with whom curently reside ate as under Name of family member. Relationship with apotcant Histher E16 no, DECLARATION: - | HEREBY DECLARE that to thebestof my knowiedge and belie (Dama etzen of nda and place of my birth s:-Town/Vlage KHANDALA Distt: Satara ‘StateJT: Maharashtra (i) Lam ordinary a resident tthe address mentioned at S.No. (a) in Form 6 since: 2007-12, Gi) lem applying for nctuston in Electoral Rol forthe first ime and my name snot included in any Assembly Constituency/Parlamentary Constituency. (Gv) dort possess any ofthe documents of age proof. Therefore, have enclosed: (Name ofthe document) n supporto age proof (Strike of, not apliabl) (0) Lam aware that making the above statement or declaration in eltion otis aplication which fase and which know or believe tobe false or de not belleve tobe tru, Is punishable under Section 31 of Representation ofthe People Act, 1960 (49 of 1950) wth imprisonment for @ term which may exten to one year or wth ie or wit oth DATE 04-03-2024 PLACE:KHANDALA ‘Accessiblity Instruction nthe light of provilons of Rights of Persons wih Disabilities Act 2016 and Rights of Persone with Disables Rules, 2017, incase of persons with intellect disability, autism, cerebral palsy and multiple disabilities ec, signature or eft hand thumb impression of person with eisai, o signature oft hand ‘thumb impression of his/her legal guaran wil be required, ‘ate: * | nease ofa married female applicant, ame of Husband may preferably be mentioned “| Submission of sef-atested copy of document wl ensure speedy delivery of services. + | incase none ofthe documents is available, fd verification is mus, As for example category ke homeless indian citizens who are otherwise eligible to become electors but donot possess any documentary proof of ordinary residence, Electoral Registration Officer shall designate an officer for field verification. ‘Ackaaledgemeateceigt Acknontedgerrent Number $1328608N0403281200016 DATE 0405-2008 Received the application n Fer 6 of Shvi/Smt/Ms, VISHAL EKANNATH LANADAGE fer Gera es [Applicant can refer the Acknowledgement Noto check te status of application] ‘+ This Is a computer generated document and does not require signature =